In Parts of Africa, H.I.V. Complicates the Question

Emmanuel Njeuhmeli is a senior biomedical prevention adviser to the United States Agency for International Development and co-chairman of the President's Emergency Plan for AIDS Relief Male Circumcision Technical Working Group.

July 10, 2012

The World Health Organization and U.N. AIDS recognize voluntary circumcision as an important H.I.V. prevention intervention in communities where H.I.V. is common and male circumcision is not. This includes many nations in East Africa and southern Africa, where the ministries of health follow the guidelines of WHO and U.N. AIDS to ensure that voluntary circumcision programs fully inform clients about the risks and benefits, and that those clients are fully capable of providing documented, informed consent before the procedure. The ministries of health adhere to this policy to avoid any possibility that men might feel pressured or coerced to undergo circumcision against their will.

According to the World Health Organization and others, only adolescent and adult patients must consent; parents can sign off for infants and children.

The position of the World Health Organization and other normative bodies, as well as the ministries of health, is that parents have the right to provide consent for circumcision on behalf of their infants and minor children, just as they have the right to consent to other preventive services like immunization. Voluntary circumcision for adolescents requires both consent from the parent or guardian and from the adolescent himself.

An estimated two-thirds of African men are already circumcised for cultural or religious reasons. Circumcision is a very ancient practice, documented as far back as ancient Egypt. Many Bantu ethnic groups practice circumcision as a rite of passage to adulthood, and most West African ethnic groups practice infant circumcision. Parents and local communities continue to circumcise their sons in settings where traditional circumcision is widely practiced.
In part because circumcision provides some protection against H.I.V., it is the non-circumcising communities in southern Africa and parts of East Africa that have the highest H.I.V. prevalence. In these regions, the self-reported prevalence of traditional male circumcision varies greatly, from 20 percent in Uganda and southern African countries to more than 80 percent in Kenya. Public health advocates may find many of these communities receptive to circumcision; some ethnic groups have a long history of circumcising young men as they are initiated into adulthood and abandoned the practice only relatively recently, during the colonial period.